View Information Collection (IC)
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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Federal IDR Process for Services relating to Nonparticipating Providers or Nonparticipating Emergency Facilities
Agency IC Tracking Number:
Is this a Common Form?
Yes
IC Status:
Modified
Obligation to Respond:
Mandatory
CFR Citation:
29 CFR 2590
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Other-Notice of Open Negotiation
2. Tri-dept - open negotiation period notice clean 9.28.21 (002).docx
Yes
Yes
Fillable Printable
Other-Notice of IDR Initiation
3. Tri-dept - notice of IDR Initiation clean 9.28.21.docx
Yes
Yes
Fillable Printable
Other-Notice of Certified IDR Entity Selection
4. Tri-dept - notice of certified IDR entity selection (data elements) clean 9.28.21.docx
Yes
Yes
Fillable Printable
Other- Notice of Agreement on an Out-of-Network Rate
5. Tri-dept - notice of agreement of OON rate (data elements) clean 9.28.21.docx
Yes
Yes
Fillable Printable
Other-Payment Settlement Form
CMS-10791- PPDR-Payment Settlement Form Notice.pdf
Yes
Yes
Fillable Printable
Other-Good Faith Estimate Template Notice
CMS-10791 - Good Faith Estimate Template Notice.pdf
Yes
Yes
Fillable Printable
Other-PPDR Data Elements for Patients and Providers
CMS-10791 - Appendix-HHS PPDR Data Elements for Patients and Providers_v2.pdf
Yes
Yes
Fillable Printable
Other-HHS Vendor Management
CMS-10791 - Appendix-HHS Vendor Management (VM) Data Elements.pdf
Yes
Yes
Fillable Printable
Other-Notice of Offer Data Elements
APPENDIX 3 Notice of Offer Data Elements.docx
Yes
Yes
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Income Security
Subfunction:
General Retirement and Disability
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
8,718
Number of Respondents for Small Entity:
7,584
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits, Not-for-profit institutions
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
13,825
0
0
82
0
13,743
Annual IC Time Burden (Hours)
27,259
0
0
837
0
26,422
Annual IC Cost Burden (Dollars)
199,430
0
0
139,268
0
60,162
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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The .gov means it's official.
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